Burden of hepatitis B and C in Europe calls for political impetus to accelerate elimination efforts
Authors: Jean-Michel Pawlotsky
Journal: The Lancet Public Health (2023)

Following WHO's 2016 resolution, the world is now engaged in a strong, albeit geographically heterogeneous, effort to eliminate viral hepatitis as a major public health threat by 2030. Specifically, the goal is to reduce the global incidence of new cases of hepatitis B and C by 90%, while reducing deaths from these two pathogens by 65%.1WHOHepatitis.https://www.who.int/health-topics/hepatitis/elimination-of-hepatitis-by-2030Date accessed: July 20, 2023Google Scholar This goal appears achievable with the tools now available for screening, diagnosis, treatment, and prevention of hepatitis B and C. However, implementation at the country level remains politically dependent and costly. The majority of countries on track to meet the 2030 elimination targets are in Europe, and particularly in western Europe. However, many European countries lag far behind or have no clear prospect of reaching the targets.2Gamkrelidze I Pawlotsky JM Lazarus JV et al.Progress towards hepatitis C virus elimination in high-income countries: an updated analysis.Liver Int. 2021; 41: 456-463Crossref PubMed Scopus (62) Google Scholar In The Lancet Public Health, the GBD 2019 Europe Hepatitis B & C Collaborators analysed data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to provide estimates of the incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of diseases caused by hepatitis B virus (HBV) and hepatitis C virus (HCV), including acute hepatitis, chronic hepatitis, cirrhosis, and hepatocellular carcinoma, and their changes between 2010 and 2019.3GBD 2019 Europe Hepatitis B & C CollaboratorsHepatitis B and C in Europe: an update from the Global Burden of Disease Study 2019.Lancet Public Health. 2023; 8: e701-e716Summary Full Text Full Text PDF Scopus (1) Google Scholar The report highlights a still significant burden of HBV and HCV infection in Europe, with important disparities in the burden of disease between countries highlighting the fact that more needs to be done to achieve the elimination targets, especially in central and eastern Europe. Notably, the burden of acute hepatitis B and HBV-related cirrhosis in Europe decreased between 2010 and 2019, reflecting effective prevention efforts. An impact on HBV-related liver cancer is expected in the coming years. By contrast, the burden of HCV-related liver cancer increased over the same period, which the authors attribute to the ageing population and the delayed effect of the recent large-scale introduction of direct-acting HCV antivirals. This study provides a timely assessment of various epidemiological markers of HBV and HCV infection at the European level. The estimates and trends provide a valuable insight into the European situation and its dynamics over the past decade. It is hoped that this information will help to guide elimination strategies and their implementation, especially in countries identified in the report as clearly being off track to meet the targets. It is essential to know where and how national and international policies have had an impact, as both examples and stimuli for other countries to start, reinvigorate, or redirect their efforts. This dataset thus provides concrete support to policy makers and stakeholders in different countries to strengthen their hepatitis elimination strategies; they should not hesitate to use it to convince decision makers to provide funding, as the benefits of such policies are clearly visible. The study has several weaknesses, which the authors thoughtfully discuss.3GBD 2019 Europe Hepatitis B & C CollaboratorsHepatitis B and C in Europe: an update from the Global Burden of Disease Study 2019.Lancet Public Health. 2023; 8: e701-e716Summary Full Text Full Text PDF Scopus (1) Google Scholar First, the results depend heavily on the quality and reliability of the data used in the analyses. Although the authors did their best to eliminate as many biases as possible, it is well known that such large datasets suffer from the heterogeneity in data quality among the countries and systems of origin. Second, medicine, especially liver medicine, is complex, and definitive attribution of a death or disease to an infectious cause is difficult, despite the presence of the infectious agent—which might be the primary cause, only a cofactor, or only opportunistically present in a patient with another abnormal liver condition. This difficulty is particularly true for acute hepatitis, which is exceptionally a cause of death or disability: indeed, fulminant HCV infections do not occur, and fulminant HBV infections remain rare, and patients with acute hepatitis who do not develop chronic infection recover promptly and without sequelae.4Westbrook RH Dusheiko G Natural history of hepatitis C.J Hepatol. 2014; 61: S58-S68Summary Full Text Full Text PDF PubMed Scopus (635) Google Scholar, 5Fattovich G Natural history of hepatitis B.J Hepatol. 2003; 39: 50-58Summary Full Text Full Text PDF PubMed Google Scholar The actual roles of HBV and HCV in the progression and complications of chronic liver disease are also often difficult to interpret. The viral infection might be the sole cause of liver disease and its complications, but comorbidities (coinfection, metabolic dysfunction, alcohol consumption, drug abuse, genetic or environmental factors, etc) are very common, and in these cases it is difficult to distinguish the effects of the infection from the effects of comorbidities.6Karlsen T Sheron N Zelber-Sagi S et al.The EASL–Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality.Lancet. 2022; 399: 61-116Summary Full Text Full Text PDF PubMed Scopus (169) Google Scholar Nevertheless, given the frequency of liver comorbidities in the general population,7Manns MP Burra P Sargent J Horton R Karlsen TH The Lancet–EASL Commission on liver diseases in Europe: overcoming unmet needs, stigma, and inequities.Lancet. 2018; 392: 621-622Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar the control of at least one condition involved in the progression of liver disease—ie, viral hepatitis—will have an impact on liver-related morbidity and mortality. The great merit of this GBD report is that it provides detailed figures and maps of the burden of HBV-related and HCV-related liver disease and its evolution during the second decade of the 21st century. Despite some limitations of the study, these figures are an invaluable resource for policy makers and other stakeholders in their efforts to bring about real change and to convince payers to move forward to achieve viral hepatitis elimination goals as early as possible, at the level of each European country. Whether elimination happens in 2030 or a few years later in some countries does not really matter, as long as it happens within a reasonable timeframe. The time to act is now. I have served as an advisor or speaker for Abbott, AbbVie, GlaxoSmithKline, and Gilead. I acknowledge the use of DeepL Write to improve the syntax during the preparation of this work; after using this tool, I reviewed and edited the content as needed and take full responsibility for the content of the publication. Hepatitis B and C in Europe: an update from the Global Burden of Disease Study 2019Although decreases in some HBV-related and HCV-related diseases were estimated between 2010 and 2019, HBV-related and HCV-related diseases are still associated with a high burden, highlighting the need for more intensive and coordinated interventions within European countries to reach the goal of elimination by 2030. Full-Text PDF Open Access